Encopresis, or fecal soiling, is the repeated, involuntary passage of stool into the underwear of a child who is already toilet trained, typically after the age of four. This condition is overwhelmingly a medical issue caused by chronic constipation, not a behavioral choice, and is completely treatable. Parents and caregivers must maintain a supportive and non-judgmental approach, understanding that the soiling results from a physical malfunction. Successful treatment involves a structured, multi-phase medical and behavioral regimen designed to restore normal bowel function.
The Underlying Mechanism of Encopresis
The soiling occurs because of a chronic cycle of constipation and retention. When a child repeatedly withholds stool, often due to a painful bowel movement, the feces remain in the colon and become hard and dry. This causes the stool mass to become impacted, meaning it is too large and firm to pass normally.
The retained stool physically stretches the rectum and the lower part of the large intestine. This sustained stretching dulls the nerve endings in the rectal wall responsible for signaling the urge to defecate. Without these proper nerve signals, the child loses the sensation that their rectum is full. Soiling happens when new, liquid stool from higher up the colon bypasses the hard, impacted mass and leaks out involuntarily, often mistaken for diarrhea.
Phase One: Initial Disimpaction and Cleanout
The first step in treatment is the medical cleanout, or disimpaction, which aims to clear the retained, hardened stool mass. This aggressive phase requires medical supervision and should not be attempted with standard, over-the-counter laxative doses, as this can worsen symptoms. The most effective method involves high-dose osmotic laxatives, typically polyethylene glycol (PEG) mixed in a liquid.
The goal of this week-long treatment is to completely evacuate the bowel until the child is passing watery, brown liquid stool without solid pieces. Healthcare providers increase the dose incrementally until this result is achieved, confirming the backlog is cleared. In severe or resistant cases, a physician may recommend adding a stimulant laxative like bisacodyl or sodium picosulphate to increase the muscular squeezing of the bowel. Rectal interventions, such as enemas or suppositories, are reserved for situations where oral medications are ineffective or the impaction is severe.
Phase Two: Long-Term Bowel Maintenance
Once the initial impaction is cleared, the focus shifts to a prolonged maintenance phase to prevent recurrence and allow the stretched bowel to shrink back to its normal size. This requires a daily regimen of lower-dose laxatives, often PEG, mineral oil, or lactulose, for several months, sometimes up to a year or more. The daily dose must be adjusted by the parent and physician to ensure the child passes at least one soft, easy-to-pass stool every day, ideally resembling the consistency of oatmeal.
This medication is not addictive or harmful when used long-term; its purpose is simply to keep the stool soft, eliminating the painful cycle that led to withholding. Alongside medication, dietary changes support soft stools. This includes increasing the child’s intake of dietary fiber through fruits, vegetables, and whole grains, while also ensuring adequate fluid intake throughout the day.
Integrating Behavioral Training and Support
Concurrent with the medical phases, behavioral training is necessary to re-establish a healthy bowel habit and retrain the rectal nerves. This involves scheduled toilet sitting, which should occur three times per day for five to ten minutes, specifically after meals. Timing the sits after eating takes advantage of the gastrocolic reflex, a natural muscular contraction that pushes waste through the colon.
Positive reinforcement is a component of this phase, rewarding the child for the effort of sitting, not for producing a bowel movement. Using a stool chart or calendar to track progress and rewarding compliance helps reinforce the routine. Maintaining a supportive atmosphere is paramount, as the soiling is involuntary and can cause shame and low self-esteem. Parents should avoid punishment or shaming and instead focus on patience and normalizing the condition to ensure the child feels safe and supported throughout recovery.